Ischaemic heart disease and stable angina: the AU GP approach

What ischaemic heart disease means in practice

Coronary heart disease (CHD) remains Australia’s single leading cause of death. According to AIHW data, approximately 1.2 million Australians are living with CHD and around 57,000 acute coronary syndrome (ACS) hospitalisations occur each year, accounting for roughly 10 per cent of all deaths nationally.

In general practice, ischaemic heart disease presents across a wide clinical spectrum. At one end sits stable angina — predictable exertional chest discomfort that reflects a supply-demand mismatch across a flow-limiting coronary stenosis. At the other end sits the ACS spectrum — unstable angina, NSTEMI, and STEMI — driven by plaque rupture or erosion with acute coronary thrombus. Between these extremes are post-infarct patients, those with revascularised coronary artery disease (CAD), and people with asymptomatic disease picked up incidentally.

The workload is substantial. Chest pain is among the top 30 presenting complaints in Australian general practice. GPs manage the ongoing care of the vast majority of Australians living with stable CHD: optimising medications, monitoring risk factors, referring for investigations, screening for depression and anxiety, and coordinating with cardiology.

Aboriginal and Torres Strait Islander Australians experience CHD events 10–20 years earlier than non-Indigenous Australians and at approximately twice the rate — a disparity that demands proactive cardiovascular risk assessment at every health assessment for this group.

A. Core clinical — the AU general practice framework

History

The Heart Foundation 2023 cardiovascular risk guideline recommends structured clinical assessment to characterise symptoms and quantify background risk.

Typical stable angina presents as central retrosternal pressure, heaviness, or tightness precipitated by exertion (walking uphill, climbing stairs, physical activity) or emotional stress, relieved within five minutes by rest or sublingual glyceryl trinitrate (GTN). Radiation to the neck, jaw, left arm, or both arms is common. The Canadian Cardiovascular Society (CCS) angina classification grades functional limitation: CCS I (strenuous exertion only) through CCS IV (rest or minimal activity).

Unstable features — the ACS red flags — are chest pain at rest, new-onset angina, or crescendo angina (increasing frequency, lower exertion threshold, longer duration, or poor response to GTN). These require emergency transfer.

Atypical presentations are important to recognise. In women, older adults, and people with diabetes, angina may present as dyspnoea, fatigue, epigastric discomfort, or jaw pain without chest pressure. A low threshold for ECG and troponin is appropriate in these groups.

Routine history should document cardiovascular risk factors (age, sex, family history of premature CVD, smoking status, T2DM, hypertension, dyslipidaemia, CKD, prior CV events); aggravating conditions (anaemia, hyperthyroidism, aortic stenosis); and psychosocial factors — depression, anxiety, sleep quality, and occupational stress all independently elevate cardiovascular risk.

Examination

• Blood pressure in both arms; heart rate and rhythm.
• Cardiac auscultation: apex beat, added sounds (S3 or S4), murmurs (particularly aortic stenosis and mitral regurgitation), peripheral oedema.
• Vascular assessment: carotid bruit, abdominal bruit, femoral pulses, pedal pulses (PAD frequently co-exists with CAD).
• Respiratory: basal crackles or pleural effusion (left ventricular failure).
• Skin: tendon xanthomas and corneal arcus (familial hypercholesterolaemia), acanthosis nigricans (insulin resistance), nicotine staining.

Investigations

First-line for any patient with suspected angina:

• Resting 12-lead ECG — MBS item 11707 for a GP-recorded and reported trace. This replaced items 11700, 11701, and 11702 from August 2020. Normal ECG does not exclude significant CAD.
• High-sensitivity troponin — a baseline result plus a 1–3 hour result if ACS is suspected. A single negative result does not rule out ACS; the serial algorithm is required.
• Fasting lipids, HbA1c, eGFR/UEC, FBC, TSH — to characterise modifiable risk factors and exclude secondary causes (anaemia, thyroid disease).
• BNP or NT-proBNP — if there are features suggestive of heart failure.
• Chest X-ray — to exclude alternative diagnoses (pneumothorax, pneumonia, pericardial effusion, widened mediastinum).
• Echocardiogram — to assess left ventricular function, regional wall-motion abnormality, and valvular disease; referral pathway via cardiologist (echo MBS items are specialist-restricted).

For stable chest pain (low-to-intermediate pre-test probability, no known CAD):

The SCOT-HEART NEJM 2018 trial demonstrated that a CT coronary angiography (CTCA)-guided strategy reduced five-year major adverse cardiac events and better identified non-obstructive disease, prompting initiation of preventive therapy. CTCA is the preferred first-line non-invasive test in this population. MBS items 57360 and 57362 provide Medicare rebate when the referrer requests specifically; the Heart Foundation has a cardiac imaging referral resource to support appropriate use.

Stress ECG, stress echocardiography, and myocardial perfusion scanning are reserved for higher pre-test probability, patients unsuitable for CTCA (heavy coronary calcification, BMI extremes), and ongoing assessment in known CAD.

Acute ACS management in the GP setting

Any patient presenting with features of ACS in general practice requires immediate action:

1. Call 000.
2. Aspirin 300 mg — chewed (not swallowed whole) immediately, per the NHFA/CSANZ ACS 2025 guideline.
3. Sublingual GTN spray 400 mcg — repeat every five minutes up to three doses, provided systolic blood pressure remains above 90 mmHg and pain persists.
4. Oxygen only if oxygen saturation is below 94% — the AVOID NEJM 2015 trial showed that supplemental oxygen in normoxic STEMI increased infarct size; restrict its use accordingly.
5. Continuous ECG monitoring with a defibrillator available.
6. Morphine 2.5–5 mg IV or SC if pain remains severe despite GTN (note: morphine slows P2Y12 inhibitor absorption — use judiciously).
7. Transfer with pre-arrival notification to a facility with primary PCI capability.

STEMI ECG recognition pitfall: posterior STEMI presents with reciprocal ST depression in V1–V3 and tall R waves. Request V7–V9 posterior leads if suspicious.

B. Secondary prevention — the evidence base

After an acute coronary event or revascularisation, the goal of general practice management shifts to preventing recurrence. The secondary prevention bundle below is drawn from the NHFA/CSANZ ACS 2025 guideline and the Australian Prescriber 2025 secondary prevention summary.

Antiplatelet therapy. Aspirin 100 mg daily is continued indefinitely. After ACS or coronary stenting, dual antiplatelet therapy (DAPT) — aspirin plus a P2Y12 inhibitor — is recommended for 6–12 months. Ticagrelor 90 mg twice daily is the preferred P2Y12 inhibitor for most ACS patients; clopidogrel 75 mg daily is used when ticagrelor is not tolerated or where bleeding risk is high. NPS guidance on antiplatelet PBS listings clarifies current Authority Required (Streamlined) criteria. In patients with atrial fibrillation plus recent coronary stenting, triple therapy (DOAC plus clopidogrel) is recommended for 6–12 months per the 2025 guideline.

Statin therapy. A high-intensity statin — atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily — is the standard. The target LDL-C is below 1.8 mmol/L. If the target is not reached on maximum-tolerated statin, add ezetimibe; PCSK9 inhibitors (evolocumab, alirocumab) are available under PBS Authority criteria for very high-risk patients. For detailed lipid management, see the dyslipidaemia and cardiovascular risk guide.

ACE inhibitor or ARB. All patients post-MI, particularly those with LVEF below 40 per cent, T2DM, hypertension, or CKD, benefit from ACE inhibitor or ARB therapy. The HOPE NEJM 2000 trial demonstrated benefit of ramipril across a broad high-CV-risk population.

Beta-blocker. Continued for at least 12 months post-MI per guideline recommendation. The REBOOT NEJM 2024 trial and the REDUCE-AMI trial showed no benefit of ongoing beta-blocker beyond 12 months in patients with preserved left ventricular ejection fraction, no atrial fibrillation, and no ongoing angina — supporting a reassessment conversation at the 12-month review rather than automatic indefinite continuation.

Mineralocorticoid receptor antagonist (MRA). Spironolactone 25–50 mg or eplerenone 25–50 mg is indicated in patients with LVEF at or below 40 per cent plus either heart failure or T2DM post-MI, per EPHESUS NEJM 2003. Monitor potassium and renal function closely.

Cardiac rehabilitation. A Cochrane review of 64 trials found cardiac rehabilitation reduces all-cause mortality by approximately 13 per cent and cardiovascular mortality by approximately 26 per cent. Refer all post-ACS and post-revascularisation patients. In Australia, state-funded outpatient programs are available through most public hospitals; telehealth-delivered cardiac rehabilitation has expanded access in regional and rural areas.

Lifestyle. Smoking cessation is the single highest-yield lifestyle intervention: a large meta-analysis found quitting after CHD reduces all-cause mortality by approximately 36 per cent. Mediterranean dietary pattern has strong supporting trial evidence (PREDIMED NEJM 2018). Exercise of at least 150 minutes weekly at moderate intensity is recommended once cleared post-event. Alcohol should be minimised. Weight reduction in those with obesity is beneficial.

Depression and anxiety screening. Depression at or shortly after a myocardial infarction independently triples mortality (Lichtman Circulation 2014). Screen with PHQ-9 at six weeks and six months post-ACS. Sertraline is safe in post-MI depression and is the preferred agent where an SSRI is indicated (SADHART JAMA 2002). Referral for psychological therapy should run alongside pharmacological treatment. A Mental Health Care Plan (MBS items 2715/2717) can be initiated concurrently with the GP Chronic Disease Management Plan.

A note on stable angina without high-risk anatomy. The ISCHAEMIA 2020 trial enrolled over 5,000 patients with stable angina and moderate-to-severe ischaemia, randomly assigning them to routine invasive management versus optimal medical therapy. There was no mortality benefit and no reduction in MI from routine revascularisation. This supports the approach of initiating optimal medical therapy first in stable angina without high-risk anatomical features, reserving revascularisation for refractory symptoms or high-risk anatomy (left main, three-vessel disease, significant proximal LAD stenosis).

C. Antianginal pharmacotherapy

The goal of antianginal therapy is to reduce the frequency and severity of anginal episodes and improve exercise tolerance. This is distinct from secondary prevention — antianginal drugs reduce symptoms but do not all reduce mortality.

Per eTG Cardiovascular and AMH:

Beta-blocker — first-line. Atenolol 25–100 mg daily, metoprolol succinate 25–200 mg daily, or bisoprolol 2.5–10 mg daily. Target resting heart rate 55–60 beats per minute. Beta-blockers reduce myocardial oxygen demand by lowering heart rate and contractility. They are first-line for stable angina and post-MI secondary prevention simultaneously.

Calcium channel blocker (CCB). Non-dihydropyridine CCBs (verapamil 80–120 mg three times daily, diltiazem 60–120 mg three times daily) reduce heart rate and are an alternative when beta-blockers are contraindicated (asthma, peripheral arterial disease). Crucially, do not combine a non-DHP CCB with a beta-blocker — the combined negative chronotropic and dromotropic effect risks bradycardia and heart block. Dihydropyridine CCBs (amlodipine 5–10 mg daily) are used as add-on therapy alongside beta-blockers without this risk.

Long-acting nitrate. Isosorbide mononitrate 30–120 mg daily is added when beta-blocker and CCB do not achieve adequate symptom control, or when these are contraindicated. A nitrate-free interval of 8–10 hours (typically overnight) is essential to prevent nitrate tolerance.

Sublingual GTN 400 mcg spray PRN. All patients with known angina should carry a GTN spray and know how to use it: sit or lie before spraying to avoid fainting; spray once under the tongue; repeat at five minutes if symptoms persist; and call 000 if pain is not relieved after two doses or after ten minutes from the first dose.

Ivabradine — for patients in sinus rhythm with heart rate at or above 70 beats per minute despite maximum-tolerated beta-blocker, specialist-initiated. The SHIFT Lancet 2010 trial demonstrated benefit in heart failure with reduced ejection fraction; PBS listing is restricted to this indication.

Second-line agents. Nicorandil, ranolazine, and perhexiline are second/third-line antianginals, generally specialist-initiated, with limited PBS access.

D. Australian operations

MBS items relevant to CHD management

• Standard GP consultations: item 23 (level B), item 36 (level C), item 44 (level D).
• 12-lead ECG: item 11707 for a GP-recorded and reported trace.
• CT coronary angiography: item 57360 (with contrast) and item 57362 (with contrast and functional assessment).
• Heart Health Check: item 699 (in person), item 177 (telehealth) — for cardiovascular risk assessment in 45–79 year olds (30–79 for Aboriginal and Torres Strait Islander patients).
• GP Chronic Disease Management Plan: item 965 (preparation) / item 967 (review). CHD qualifies as a chronic condition; up to five allied health visits per year (10 for Aboriginal and Torres Strait Islander patients). Note items 721/723/732 were replaced by items 965/967 and telehealth equivalents from 1 July 2025.
• ATSI Health Assessment: item 715, claimable every nine months.
• Practice nurse follow-up: item 10997.
• Mental Health Care Plan: item 2715 (preparation) / item 2717 (review).
• Pathology: lipids item 66536, HbA1c item 66551, eGFR/UEC item 66500, BNP/NT-proBNP item 66830, troponin item 66514.

PBS-relevant prescribing notes

Aspirin 100 mg is available on general schedule. Clopidogrel 75 mg, ticagrelor 90 mg and 60 mg, and prasugrel 5 mg and 10 mg are Authority Required (Streamlined) for ACS and post-PCI patients meeting PBS criteria. Beta-blockers, ACE inhibitors, ARBs, DHP CCBs, non-DHP CCBs, and long-acting nitrates are all available on general schedule. Ezetimibe and statins are general schedule; PCSK9 inhibitors require PBS Authority (high-CV-risk criteria). Ivabradine is Authority Required for HFrEF criteria. Colchicine received TGA approval for secondary CV prevention in 2022; PBS subsidy for this indication is pending — patient cost if private.

Driving and fitness to drive

The Austroads Assessing Fitness to Drive guidelines govern return to driving after coronary events:

• Private licence: usually fit at two weeks post-uncomplicated PCI; four weeks post-CABG or uncomplicated MI.
• Commercial licence: four weeks post-uncomplicated PCI; three months post-CABG; four weeks post-uncomplicated MI. Cardiologist clearance is typically required. Advise all patients about driving restrictions at the time of diagnosis or intervention. Document the advice in the clinical record.

E. Special populations

Women, older adults, and people with diabetes

Atypical angina presentation is substantially more common in these groups — dyspnoea, fatigue, jaw pain, epigastric discomfort, or back pain without classic chest pressure. MINOCA (myocardial infarction with non-obstructive coronary arteries) affects approximately 5–15 per cent of MIs overall and disproportionately affects women, reflecting underlying mechanisms of plaque erosion, coronary vasospasm, microvascular dysfunction, spontaneous coronary artery dissection (SCAD), and takotsubo cardiomyopathy. A low threshold for ECG and troponin assessment is appropriate; do not attribute atypical symptoms to anxiety without objective investigation.

Aboriginal and Torres Strait Islander Australians

CHD onset occurs 10–20 years earlier and event rates are approximately double those of non-Indigenous Australians. Proactive cardiovascular risk assessment at every ATSI Health Assessment (item 715) is essential. Absolute cardiovascular risk tools (the Australian CV risk calculator at cvdcheck.org.au) should be used routinely from age 30 in this group, and earlier when risk factors are present. Culturally safe care, community health worker involvement, and coordination with Aboriginal Community Controlled Health Organisations (ACCHOs) are important to support adherence and follow-up.

Depression and anxiety post-ACS

Depression occurs in approximately 15–25 per cent of patients following a myocardial infarction and is an independent predictor of mortality, hospital readmission, and reduced quality of life. Routine PHQ-9 screening at six weeks and six months post-ACS is recommended. Where an SSRI is clinically indicated, sertraline has the most safety data in this population. Psychological therapy — cognitive behavioural therapy for post-cardiac depression and anxiety — can be accessed via the Better Access initiative. Do not defer mental health treatment in post-ACS patients: the evidence base supports its safety and potential benefit.

Pregnancy and CHD

Pregnancy in women with known CHD is a specialist domain. Many antianginal and secondary prevention medications are contraindicated or require review. Refer to a high-risk obstetric team. Aspirin at low dose is commonly continued under specialist guidance for secondary prevention in pregnancy where clearly indicated.

When to escalate

Refer urgently or arrange emergency transfer when:

• Suspected ACS — any ACS features (call 000 before referral if in clinic).
• Refractory chest pain not settling with GTN and rest.
• STEMI on ECG — direct transfer for primary PCI.
• New heart failure with suspected MI or decompensation.
• Accelerating angina (crescendo pattern) or dramatically worsened functional class.
• Troponin rise in any context.
• High pre-test probability for left main or three-vessel disease.

Refer routinely (non-urgent cardiology):

• Stable angina refractory to two antianginal agents needing revascularisation assessment.
• Suspected vasospastic or microvascular angina (INOCA).
• Complex arrhythmia or structural heart disease.
• Significant valvular disease identified on examination.
• Ivabradine or PCSK9 inhibitor initiation.

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — NHFA/CSANZ, Heart Foundation, eTG, AMH, NPS MedicineWise, RACGP — and major cardiovascular trials. It is not personal medical advice and does not create a doctor–patient relationship. Individual clinical decisions, including medication selection and investigation planning, are made with your own GP and treating specialists.

For Australian consumer-friendly resources: HealthDirect — Angina, HealthDirect — Heart attack, Heart Foundation — Living with coronary heart disease, Heart Foundation My Heart, My Life, Better Health Channel.

If you have chest pain now: call 000.

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Sources cited

1. NHFA / CSANZ — Australian Clinical Guideline for Diagnosing and Managing ACS 2025
2. Australian Prescriber — Secondary prevention of ACS: 2025 summary
3. Australian Prescriber — Medical management of chronic stable angina
4. Heart Foundation — Australian guideline for assessing and managing CV risk (2023)
5. Therapeutic Guidelines (eTG) — Cardiovascular
6. Australian Medicines Handbook (AMH)
7. NPS MedicineWise — Antiplatelet listings
8. RACGP Red Book — Secondary prevention CHD
9. AIHW — Heart, stroke and vascular disease facts
10. ISCHAEMIA 2020 — NEJM 2020
11. SCOT-HEART trial — NEJM 2018
12. AVOID trial — NEJM 2015
13. REBOOT trial — NEJM 2024
14. HOPE trial — NEJM 2000
15. EPHESUS — NEJM 2003
16. Cardiac rehabilitation — Cochrane 2016
17. PREDIMED — NEJM 2018
18. Lichtman — Depression and mortality post-MI (Circulation 2014)
19. SADHART — Sertraline post-MI (JAMA 2002)
20. SHIFT — Ivabradine in HF (Lancet 2010)
21. MBS Online
22. PBS Online
23. Austroads — Assessing Fitness to Drive 2022
24. HealthDirect — Angina · Heart attack
25. Heart Foundation — Living with CHD · My Heart, My Life
26. Better Health Channel — Heart attack